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The nurse has just administered morphine 4 mg IV to a client with severe pain from a kidney stone. The client then asks to get up to the toilet. Which is the correct nursing action for this client?
- A. assist the client to the toilet
- B. offer the client a bedpan or urinal
- C. obtain an order for a Foley catheter
- D. place a bedside commode in the room
Correct Answer: B
Rationale: Morphine can cause sedation and dizziness, increasing fall risk. Offering a bedpan or urinal is safer than ambulating to the toilet.
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A client seen in the emergency department for influenza asks for an antibiotic prescription. Which of the following guidelines are important in helping the client decrease the risk of developing an antibiotic-resistant infection? Select all that apply.
- A. Stop taking antibiotics as soon as symptoms subside.
- B. Do not take antibiotics for viral infections, as they do no good.
- C. Do not take preventive antibiotics to avoid infection.
- D. Follow prescription directions when taking antibiotics.
- E. Take the same antibiotic for every infection.
Correct Answer: B,C,D
Rationale: Avoid antibiotics for viral infections (B), avoid prophylactic antibiotics (C), and follow prescription directions (D) reduce resistance. Stopping early (A) or reusing antibiotics (E) promotes resistance.
The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:
- A. Swelling of the hands and increased temperature
- B. Increased heart rate and increased blood pressure
- C. Swelling of the feet and increased temperature
- D. Decreased heart rate and decreased blood pressure
Correct Answer: B
Rationale: Fluid overload in infants can cause increased heart rate and blood pressure due to increased intravascular volume.
The nurse is reviewing a new client's medication orders. Which order would prompt the nurse to notify the health care provider?
- A. allopurinol 300 mg PO daily
- B. potassium chloride 20 mEq PO daily
- C. warfarin (Coumadin) 50 mg PO daily
- D. metoprolol (Lopressor) 50 mg PO daily
Correct Answer: C
Rationale: A 50 mg dose of warfarin is unusually high and likely a dosing error, requiring provider clarification. Other orders are within typical ranges.
A client is receiving a blood transfusion following surgery. In the event of a transfusion reaction, any unused blood should be:
- A. Sealed and discarded in a red bag
- B. Flushed down the client's commode
- C. Sealed and discarded in the sharp's container
- D. Returned to the blood bank
Correct Answer: D
Rationale: Unused blood must be returned to the blood bank for analysis in case of a transfusion reaction.
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.